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First Name:
Last Name:
Date of Birth:
Email:
Country of residence:
Mailing zip code:
Are you or a family member currently on oxygen therapy?	Yes No
If yes, for what condition?	Alpha 1Antitrypsin deficiency Asthma COPD Cystic fibrosis Emphysema Other:
If yes, How long have you (or your loved on) been living with your condition?	years
How did you hear about the OxygeNation website?
Are you a member of any third party or patient support groups for lung disorders (i.e. American Lung Assocation)?	Yes No
If yes, please list:
How do you currently recieve information on oxygen theraphy related to your (or your loved one's) condition?	Family & Friends Internet Physician/healthcare provider Other:
What would you like to see an online community offer?
What would encourage you to join an online community for oxygen users?